Inspection Reports for St. Anne’s Center dba Lantern House (RS)
269 W 33rd St., Ogden, UT, 84401
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
13.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Renewal
Census: 333
Capacity: 333
Deficiencies: 6
Date: Jan 28, 2025
Visit Reason
The inspection was an announced renewal licensing inspection conducted to assess compliance with licensing rules and regulations for Lantern House.
Findings
The inspection identified multiple noncompliance issues across various regulatory areas including licensing procedures, program policies, physical facilities, staffing, and client record requirements. Several deficiencies were noted related to medication management, physical facility maintenance, and staff training. Some issues were corrected during the inspection while others require follow-up.
Deficiencies (6)
Noncompliance with licensing procedures including accepting fees before license approval and maintaining current staff rosters.
Failure to comply with program policies and safe practices including medication management and supervision.
Physical facility deficiencies including missing soap and paper towels, holes in walls, HVAC issues, and cleanliness problems.
Inadequate staffing levels and failure to identify a qualified manager or designee.
Incomplete client records and intake/discharge documentation.
Lack of required personnel training and documentation.
Report Facts
Number of Non Compliant Items: 1
Approved Capacity: 333
Census: 333
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Navidomskis | Individual informed of the inspection. | |
| Shelisa York | Licensor | Licensor conducting the inspection. |
Inspection Report
Annual Inspection
Capacity: 330
Deficiencies: 23
Date: Feb 5, 2024
Visit Reason
The inspection was an announced annual licensing inspection conducted to assess compliance with licensing rules and regulations for Lantern House.
Findings
The inspection identified multiple noncompliance issues across various regulatory areas including licensing procedures, program policies, staffing, client records, intake and discharge requirements, clinical services, physical facilities, food service, and specialized services. Several deficiencies were noted related to staff qualifications, training, client intake screenings, and program documentation.
Deficiencies (23)
Noncompliance with new and renewal licensing procedures including accepting fees before license approval and allowing immediate unrestricted access.
Noncompliance with variances and inspection/investigation process rules.
Failure to develop, implement, and comply with safe practices ensuring client health and safety.
Failure to submit changes to office-approved policies before implementation.
Noncompliance with medication management safe practices.
Failure to ensure care, vaccination, licensure, and maintenance of animals on-site.
Failure to provide separate space for clients showing symptoms of infectious disease.
Failure to ensure staff to client ratio during transports is based on safety assessments.
Failure to clearly identify services, complaint processes, eligibility criteria, and fees to clients and public.
Failure to post required notices including abuse reporting laws, civil rights, ADA, and client rights posters.
Failure to maintain compliance with capacity determinations and vehicle licensure.
Failure to maintain current staff and client lists and organizational structure documentation.
Failure to maintain opioid overdose reversal kit with trained staff when serving clients with substance use disorder.
Failure to ensure adequate staffing with at least two on-duty staff at all times.
Failure to maintain physical facility standards including cleanliness, safety, privacy, and adequate space.
Failure to maintain medication storage and hazardous items securely.
Failure to maintain client records including intake screening, discharge documentation, treatment plans, and progress notes.
Failure to complete suicide risk screening for all clients during intake.
Failure to ensure clinical and medical staff are licensed or certified and supervised appropriately.
Failure to assign clinical director and ensure treatment plans are individualized, reviewed, and signed timely.
Failure to provide adequate staffing and ensure staff have required background clearances and training.
Two staff missing applicable qualifications, experience, or licenses.
Three staff missing first aid training; additional training topics missing for some staff.
Report Facts
Number of Non Compliant Items: 4
Total Capacity: 330
Date to be corrected: 2024
Clients missing suicide risk screener: 3
Staff missing qualifications: 2
Staff missing first aid training: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shelisa York | Licensor | Conducted the inspection |
| Lauren Navidomskis | Individual informed of the inspection and signed checklist |
Inspection Report
Renewal
Capacity: 333
Deficiencies: 12
Date: Feb 16, 2023
Visit Reason
The inspection was conducted as an annual renewal inspection of the Lantern House congregate care facility to ensure compliance with licensing and regulatory requirements.
Findings
The inspection identified multiple areas of noncompliance across various regulatory requirements including program administration, staffing, physical facilities, client records, and specialized services. Several deficiencies were noted but many were corrected during the inspection or have plans for correction.
Deficiencies (12)
Noncompliance with licensing application and monitoring procedures, including unrestricted access to site, records, clients, and staff.
Noncompliance with program changes reporting requirements.
Noncompliance with rule variances terms.
Noncompliance with required approvals for policies, curriculums, and updates.
Noncompliance with investigations of alleged noncompliances reporting.
Noncompliance with licensee noncompliance requirements.
Noncompliance with program administration and direct service requirements.
Missing signatures on licensing rule, opioid reversal, incident reporting, and program emergency response plan.
Missing 4th quarter fire drill documentation.
Noncompliance with medication storage and management requirements.
Noncompliance with personnel record requirements including grievances and incident reports in client files.
Noncompliance with various residential support program requirements including staffing, administration, and client documentation.
Report Facts
Approved Capacity: 333
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Summer Rohwer | Individual Informed of this Inspection | Named as the individual informed of the inspection and signed the checklist |
| Shelisa York | Licensor | Conducted the inspection |
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